Healthcare Provider Details

I. General information

NPI: 1699134973
Provider Name (Legal Business Name): BRANDON AMADEO BERKLEY-VIGIL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 11/01/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 WASHINGTON AVE
HIGHWOOD IL
60040-1122
US

IV. Provider business mailing address

3 CRESTVIEW TER
BUFFALO GROVE IL
60089-2107
US

V. Phone/Fax

Practice location:
  • Phone: 847-909-2004
  • Fax: 847-433-8906
Mailing address:
  • Phone: 847-909-2004
  • Fax: 847-433-8906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.005755
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: